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Ivan Aprahamian,1,2 Marcus K Borges,3 Denise J C Hanssen,2 Hans W Jeuring,2 Richard C Oude Voshaar2 1Group of Investigation on Multimorbidity and Mental Health in Aging (GIMMA), Geriatrics Division, Department of Internal Medicine, Jundiaí Medical School, Jundiaí, Brazil; 2University of Groningen, University Medical Center Groningen, Department of Psychiatry, Groningen, the Netherlands; 3Federal University of Paraná, Department of Psychiatry, Curitiba, BrazilCorrespondence: Ivan Aprahamian, Group of Investigation on Multimorbidity and Mental Health in Aging (GIMMA), Division of Geriatrics, Department of Internal Medicine, Jundiaí Medical School, Jundiaí, Brazil, Email ivan.aprahamian@gmail.comAbstract: Although the public importance of frailty is widely acknowledged by the World Health Organization, physical frailty is still largely neglected in geriatric mental health care. Firstly in this narrative review, we summarize the knowledge on the epidemiology of the association between depression and frailty, whereafter implications for treatment will be discussed. Even though frailty and depression have overlapping diagnostic criteria, epidemiological studies provide evidence for distinct constructs which are bidirectionally associated. Among depressed patients, frailty has predictive validity being associated with increased mortality rates and an exponentially higher fall risk due to antidepressants. Nonetheless, guidelines on the treatment of depression neither consider frailty for risk stratification nor for treatment selection. We argue that frailty assessment enables clinicians to better target the pharmacological and psychological treatment of depression as well as the need for interventions targeting primarily frailty, for instance, lifestyle interventions and reduction of polypharmacy. Applying a frailty informed framework of depression treatment studies included in a meta-analysis reveals that the benefit–harm ratio of antidepressants given to frail depressed patients can be questioned. Nonetheless, frail-depressed patients should not withhold antidepressants as formal studies are not available yet, but potential adverse effects should be closely monitored. Dopaminergic antidepressants might be preferable when slowness is a prominent clinical feature. Psychotherapy is an important alternative for pharmacological treatment, especially psychotherapeutic approaches within the movement of positive psychology, but this approach needs further study. Finally, geriatric rehabilitation, including physical exercise and nutritional advice, should also be considered. In this regard, targeting ageing-related abnormalities underlying frailty that may also be involved in late-life depression such as low-grade inflammation might be a promising target for future studies. The lack of treatment studies precludes firm recommendations, but more awareness for frailty in mental health care will open a plethora of alternative treatment options to be considered.Keywords: frailty, depression, depressive disorder

Marina Maria Biella,1 Marcus Kiiti Borges,1 Jason Strauss,2 Sivan Mauer,3 José Eduardo Martinelli,4 Ivan Aprahamian1,4 1Department and Institute of Psychiatry, Faculty of Medicine, University of São Paulo, São Paulo, Brazil; 2Geriatric Psychiatry, Cambridge Health Alliance, Harvard Medical School, Boston, MA, USA; 3Department of Psychiatry, Tufts Medical Center, Tufts University Scholl of Medicine, Boston, MA, USA; 4Geriatrics & Psychiatry Division, Department of Internal Medicine, Faculty of Medicine of Jundiaí, Jundiaí, BrazilCorrespondence: Ivan AprahamianGroup of Investigation on Multimorbidity and Mental Health in Aging (GIMMA), Internal Medicine Department, Faculty of Medicine of Jundiaí, Jundiaí, BrazilEmail ivan.aprahamian@gmail.comAbstract: This study aims to carry out a narrative review, aiming to update the literature on subsyndromic depression (SD), which is the most prevalent depressive disorder in older adults, and no formal guidelines or consensus are dedicated to this topic. We carried out an electronic search for articles on SD. Relevant articles were retrieved from Pubmed, EMBASE and Web of Science using the search terms “subthreshold depression,” “prevalence,” “treatment” and “older adults” in several combinations. Original articles in English were included from inception to 1st March 2019. No clear consensus exists in the literature on its nosologic classification, diagnostic tools, causes, course, outcomes or management. SD diagnosis should base in depressive symptoms scales and DSM criteria. Treatment relies mainly on collaborative care and psychotherapy. SD is relevant in clinical practice and research in geriatric psychiatry. Given the negative outcomes and potential benefits of treatment, we recommend brief psychotherapy as first-line treatment and use of psychotropic agents in cases with greater severity and/or functional impairment in association with psychotherapy. SD can precede major depressive disorder, but it also may consist of a primary depressive disorder in older adults. Furthermore, adequate treatment of SD can prevent or reduce negative outcomes associated with depressive symptoms such as worsening of clinical comorbidities, loss of functionality, increased demand for health services, and increased mortality.Keywords: subthreshold depression, prevalence, treatment, depressive symptoms, older adults